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Incontinence - urinary, in women - Management
Overview of management

  • Make an assessment.
    • Determine whether the woman has stress urinary incontinence, urgency incontinence associated with overactive bladder syndrome, mixed urinary incontinence, or rarely some other cause (such as chronic urinary retention [overflow incontinence] or fistula).
    • Refer if the urinary incontinence is not stress urinary incontinence, urgency incontinence associated with an overactive bladder, or mixed urinary incontinence.
    • Identify causes that may exacerbate or co-exist with urinary incontinence or that may need referral for further investigations. Perform a dipstick analysis of the urine in all women presenting with urinary incontinence to test for blood, leukocytes, protein, nitrites, and glucose.
    • Determine how severe the incontinence is.
    • Determine the effect of the incontinence on the the woman's quality of life.
  • Advise:
    • Weight loss if the woman's body mass index is greater than 30 kg/m2.
    • Adjustment of fluid intake if it is excessively high or low.
  • Treat any underlying causes. In frail elderly women, particularly look for delirium and restricted mobility.
  • Management depends on the predominant cause.
    • Dominant symptoms and signs of stress urinary incontinence:
      • Refer for full assessment and consideration for a programme of supervised pelvic floor muscle training for at least 3 months.
      • If conservative treatment fails or if the woman expresses a preference, offer referral to a urologist, urogynaecologist, or gynaecologist.
      • Consider offering duloxetine as a second-line treatment if the woman prefers pharmacological to surgical treatment or is not suitable for surgical treatment.
    • Dominant symptoms of urgency incontinence associated with overactive bladder syndrome:
      • Recommend caffeine reduction if appropriate.
      • Refer for full assessment and consideration of bladder training for a minimum of 6 weeks.
      • If ineffective, offer immediate-release oxybutynin. If this is not tolerated, consider other antimuscarinic drugs (darifenacin, fesoterodine, solifenacin, tolterodine, and trospium) or an alternative formulation of oxybutynin (modified-release tablets or transdermal patches).
      • Consider propiverine to treat frequency without urinary incontinence, intravaginal oestrogen for postmenopausal women with vaginal atrophy, and desmopressin for troublesome nocturia.
      • If conservative measures fail, refer for urodynamic investigations and consideration of sacral nerve stimulation, treatment with botulinum toxin, or surgery.
  • Recommend the use of absorbent pads or containment devices only when appropriate.

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